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Munawar T, Ibe U, Jiwa N, Raissi S. Renal cholesterol crystal embolism in the setting of warfarin use. BMJ Case Rep 2019; 12:12/8/e230314. [PMID: 31439554 DOI: 10.1136/bcr-2019-230314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 73-year-old man presented for evaluation of weakness and black tarry stools that occurred 1 day prior to admission. His medical history is significant for diabetes mellitus, stage 3 chronic kidney disease and deep vein thrombosis on warfarin. He was admitted to the hospital and was found to have acute kidney injury and gastrointestinal bleeding due to a supratherapeutic International Normalized Ratio. His hospital course was complicated by persistent decline in his renal function. He was given intravenous fluid resuscitation, fresh frozen plasma and packed red blood cells for his acute blood loss anaemia. Urinalysis was consistent with acute tubular necrosis. Given the persistent rise in creatinine, a kidney biopsy was obtained, and was significant for mild inflammatory changes, without evidence of vasculitis or allergic interstitial nephritis. Histopathological examination with tissue fixation revealed cholesterol embolisation. Given that he had no recent endovascular procedure or instrumentation, this atheroembolic event was attributed to his warfarin use.
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Affiliation(s)
- Tooba Munawar
- Internal Medicine, St. Mary's Hospital, Waterbury, Connecticut, USA
| | - Uzochukwu Ibe
- Internal Medicine, St. Mary's Hospital, Waterbury, Connecticut, USA
| | - Nasheena Jiwa
- Internal Medicine, St. Mary's Hospital, Waterbury, Connecticut, USA
| | - Sina Raissi
- Nephrology, St. Mary's Hospital, Waterbury, Connecticut, USA
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2
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McKinlay J, Tyson E, Forni LG. Renal complications of anaesthesia. Anaesthesia 2019; 73 Suppl 1:85-94. [PMID: 29313905 DOI: 10.1111/anae.14144] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/15/2022]
Abstract
Peri-operative acute kidney injury is common, accounting for 30-40% of all in-hospital cases of acute kidney injury. It is associated with clinically significant morbidity and mortality even with what was hitherto regarded as relatively trivial increases in serum creatinine, and carries over a 12-fold relative risk of death following major abdominal surgery. Comorbid conditions such as diabetes, hypertension, liver disease and particularly pre-existing chronic kidney disease, as well as the type and urgency of surgery, are major risk factors for the development of postoperative acute kidney injury. As yet, there are no specific treatment options for the injured kidney, although there are several modifiable risk factors of which the anaesthetist should be aware. As well as the avoidance of potential nephrotoxins and appropriate volume balance, optimal anaesthetic management should aim to reduce the risk of postoperative renal complications. This may include careful ventilatory management and blood pressure control, as well as appropriate analgesic strategies. The choice of anaesthetic agent may also influence renal outcomes. Rather than concentrate on the classical management of acute kidney injury, this review focuses on the potential development of acute kidney injury peri-operatively, and the means by which this may be ameliorated.
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Affiliation(s)
- J McKinlay
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Intensive Care Medicine, University of Surrey, Surrey, UK
| | - E Tyson
- Department of Intensive Care Medicine, Royal Surrey County Hospital, University of Surrey, Surrey, UK
| | - L G Forni
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Intensive Care Medicine, University of Surrey, Surrey, UK.,Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Clinical and Experimental Medicine, Faculty of Health Care Sciences, University of Surrey, Surrey, UK
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3
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Mulay SR, Anders HJ. Crystal nephropathies: mechanisms of crystal-induced kidney injury. Nat Rev Nephrol 2017; 13:226-240. [DOI: 10.1038/nrneph.2017.10] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Cholestrol emboli syndrome: acute renal insufficiency after a procedure or a thrombolytic therapy or anticoagulant therapy. Indian J Surg 2014; 75:432-5. [PMID: 24426640 DOI: 10.1007/s12262-012-0669-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 06/21/2012] [Indexed: 10/27/2022] Open
Abstract
Cholesterol emboli syndrome is due to dislodgment of cholesterol crystals from the atherosclerotic plaques lining the walls of major arteries resulting in an occlusion of small arteries. We describe a case of severe cutaneous and renal cholesterol emboli syndrome following coronary angiography showing our observation that this syndrome is often unrecognized or misdiagnosed and that a better evaluation of risks factors in patients undergoing invasive procedures could prevent this severe complication.
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Peripheral vascular complication from coronary angiography: A case report of cholesterol embolization. Int J Angiol 2011. [DOI: 10.1007/s00547-006-1098-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Paraskevas KI, Koutsias S, Mikhailidis DP, Giannoukas AD. Cholesterol Crystal Embolization:A Possible Complication of Peripheral Endovascular Interventions. J Endovasc Ther 2008; 15:614-25. [DOI: 10.1583/08-2395.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Acute renal artery embolism: a case report and brief literature review. Ann Vasc Surg 2008; 22:145-7. [PMID: 18083341 DOI: 10.1016/j.avsg.2007.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Revised: 06/11/2007] [Accepted: 07/16/2007] [Indexed: 12/18/2022]
Abstract
Acute renal artery embolism is an uncommon clinical diagnosis. We present a case report of a patient who was treated with transcatheter thrombolysis and a literature review and discussion of this condition and its management.
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Tan J, Afzal I, Yeadon A, Bird N, Gouldesbrough D, Akbani H. Spontaneous cholesterol embolisation causing acute renal failure. Clin Exp Nephrol 2007; 11:235-237. [PMID: 17891352 DOI: 10.1007/s10157-007-0482-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Accepted: 06/05/2007] [Indexed: 10/22/2022]
Abstract
We present a case of true spontaneous cholesterol embolisation causing acute renal failure. There was no history of vascular procedural interventions or thrombolytic therapy prior to her presentation, but the patient did have a history of difficult hypercholesterolemia and atherosclerosis. This case highlights the importance of remembering cholesterol embolisation as a potential cause of acute renal failure despite no apparent precipitant, especially with the presence of unexplained eosinophilia.
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Affiliation(s)
- Jackson Tan
- Department of Renal Medicine, St Luke's Hospital, Little Horton Lane, Bradford, BD5 0NA, England.
| | - Imran Afzal
- Department of Renal Medicine, St Luke's Hospital, Little Horton Lane, Bradford, BD5 0NA, England
| | - Adele Yeadon
- Department of Renal Medicine, St Luke's Hospital, Little Horton Lane, Bradford, BD5 0NA, England
| | - Nicholas Bird
- Department of Renal Medicine, St Luke's Hospital, Little Horton Lane, Bradford, BD5 0NA, England
| | - David Gouldesbrough
- Department of Renal Medicine, St Luke's Hospital, Little Horton Lane, Bradford, BD5 0NA, England
| | - Habib Akbani
- Department of Renal Medicine, St Luke's Hospital, Little Horton Lane, Bradford, BD5 0NA, England
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Affiliation(s)
- Rachel Hilton
- Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London SE1 9RT.
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Erdim M, Tezel E, Biskin N. A case of skin necrosis as a result of cholesterol crystal embolisation. J Plast Reconstr Aesthet Surg 2006; 59:429-32. [PMID: 16756262 DOI: 10.1016/j.bjps.2005.09.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Cholesterol crystal embolism is a multisystem disorder with a high mortality. It is usually seen following vascular surgery and long term anticoagulation therapy, but the diagnosis is often not considered. Skin manifestations are the first sign of cholesterol crystal embolism and recognition of the symptoms is a key element in early diagnosis and prevention of recurrences. We report a case who presented with acute renal failure, livedo reticularis and skin necrosis following angioplasty. Cutaneous biopsy revealed cholesterol crystals in the lumen of a vessel. Necrotic sites were treated with daily wound care and he was operated for reconstruction of tissue defects with cutaneous advancement flaps. One month after the operation healing was complete.
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Affiliation(s)
- Melike Erdim
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Marmara University, Tophanelioglu Caddesi, Altunizade, Uskudar, Istanbul, Turkey
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Matsumura T, Matsumoto A, Ohno M, Suzuki S, Ohta M, Suzuki E, Takenaka K, Hirata Y, Fujita T, Nagai R. A Case of Cholesterol Embolism Confirmed by Skin Biopsy and Successfully Treated with Statins and Steroids. Am J Med Sci 2006; 331:280-3. [PMID: 16702800 DOI: 10.1097/00000441-200605000-00010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although cholesterol embolism syndrome was recognized as a clinicopathologic entity more than 50 years ago, it is attracting growing attention recently. It is a multisystemic disorder in which cholesterol crystals released from atherosclerotic plaques obstruct small arterioles, resulting in local ischemia and end-organ damage. There are no established treatments, and with the limited treatment options available, it is important to make the diagnosis as early as possible. We present the case of a 68-year-old man with cholesterol embolism who had a few fluttering atheromas in the aorta, as demonstrated by transesophageal ultrasonography. The diagnosis was confirmed by skin biopsy, and treatment with statins and steroids proved effective, as renal failure progressively improved. This case emphasizes the importance of early diagnosis and shows the possible therapeutic effects of statins and steroids for patients with this syndrome.
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Affiliation(s)
- Takayoshi Matsumura
- Department of Cardiovascular Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Hara S, Asada Y, Fujimoto S, Marutsuka K, Hatakeyama K, Sumiyoshi A, Eto T. Atheroembolic renal disease: clinical findings of 11 cases. J Atheroscler Thromb 2003; 9:288-91. [PMID: 12560589 DOI: 10.5551/jat.9.288] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Atheromatous embolism is a systemic disease resulting from cholesterol crystal embolization in many organs, including the kidneys. To characterize atheroembolic renal disease (AERD), we retrospectively evaluated 11 patients with acute renal failure after vascular surgery, vascular radiology investigations, and anticoagulation at Miyazaki Medical College from 1994 to 2001. The diagnosis of cholesterol atheromatous embolism was confirmed by tissue examination or clinical grounds. The patients were all elderly men (average age of 66.8 years) with a history of hypertension (55%), diabetes mellitus (45%), hyperlipidemia (45%), and coronary artery disease (18%). Seven patients had livedo reticularis, and 4 had blood eosinophilia. Clinically, 7 patients were managed conservatively and 5 of them improved, whereas 4 patients required dialysis and developed chronic renal failure or died. The serum creatinine levels of the improved patients were significantly lower (1.28+/-0.3 mg/dl, p < 0.005) than the non-improved ones (7.70+/-3.6). The number of eosinophils was significantly higher in the improved patients (576+/-295 /ml, p < 0.05) than in the non-improved ones (208+/-206). However, no significant difference was observed in the levels of serum cholesterol and C-reactive protein among these patients. Since the population at risk for AERD is growing, we should recognize this disease as a cause of acute renal failure.
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Affiliation(s)
- Seiichiro Hara
- First Department of Internal Medicine, Miyazaki Medical College, Kiyotake, Miyazaki, Japan.
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Abstract
Cholesterol embolic disease is a devastating complication of atherosclerosis. Universally recommended treatment is lacking thus far. Recent data suggest that a therapeutic protocol aimed at specifically combating three causes of mortality, recurrent bouts of cholesterol embolism, cardiac failure, and cahexia, were associated with a favorable clinical outcome. As for drug therapy, corticosteroid has been reported to be beneficial in reducing local and general inflammatory responses. Concerning apheresis, combined therapy consisting of plasma exchange and low to intermediate-dose corticosteroid therapy has been shown to be effective in multivisceral cholesterol embolism. Low density lipoprotein (LDL) apheresis has been reported to be beneficial for cholesterol embolism-induced damage to the skin and brain.
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Affiliation(s)
- Midori Hasegawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyake, Aichi, Japan.
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Mieszczanska H, Lazar J, Marzo KP, Cunha BA. Cholesterol emboli mimicking acute bacterial endocarditis. Heart Lung 2002; 31:452-4. [PMID: 12434147 DOI: 10.1067/mhl.2002.129167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hanna Mieszczanska
- Division of Cardiology, Winthrop-University Hospital, Mineola, New York 11501, USA
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Schanz S, Metzler G, Metzger S, Rassner G, Fierlbeck G. Cholesterol embolism: an often unrecognized cause of leg ulcers. Br J Dermatol 2002; 146:1107-8. [PMID: 12072093 DOI: 10.1046/j.1365-2133.2002.47325.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Aird WC, Mark EJ. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 15-2002. A 53-year-old man with a myocardial infarct and thromboses after coronary-artery bypass grafting. N Engl J Med 2002; 346:1562-70. [PMID: 12015397 DOI: 10.1056/nejmcpc020015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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